APPLICATIONS 2019/2020 (June – May)

(The application is valid for one year from date of receipt)

• The forms are available from the offices of Badisa Knysna for a non-refundable, once off. administrative fee of R70.00

• The application must be completed in full otherwise it will not be processed

• The financial declaration must be certified by a Commissioner of Oaths. Please note that there is no such service available at Loeriehof.

• Tariffs are valid from 1 June – 31 May and financial declarations must be submitted annually. Tariffs are adjusted annually with approximately 10% per annum.

• The medical practitioner’s report may only be completed by a qualified, certified medical practitioner or clinic nursing sister.

• The Department of Social Development is responsible for the Social Worker report and can be contacted at 044 382 0056 for the Social Worker report that has to accompany the application.

• All applications are subject to a selection process that may include a home visit from a Nurse and/or Social Worker.

• Please Note: Loeriehof has limited subsidized space available for lower income applicants

• Please note that selections are done as space becomes available in the Home, but enquiries are welcome at any time

• Flat rental is R4 900.00 per month for a single flat; R6 100.00 for a double flat and includes lunch, weekly cleaning and weekly laundry service.

• Skoolhuis rooms are R1 310.00 per month per room en includes daily lunch, weekly cleaning of rooms, access to a washing machine and monthly clinic at Loeriehof.

• Assisted Living costs R7 260.00 per month which includes all meals, tea/coffee, weekly cleaning of rooms, laundry and access to care staff.

• Frail Care costs R7 700.00 per month and includes all meals, coffee/tea, cleaning and laundry service with preferred access to care staff.

Frail Care

FACILITY: LOERIEHOF HOME FOR THE ELDERLY Assisted Living

Flat

Skoolhuis

1. SURNAME: _____________________________________________________

2. FULL NAMES: ___________________________________________________

3. ID.NO:

4. DATE OF BIRTH:

5. CURRENT ADDRESS:

________________________________________________________________

________________________________________________________________

WHERE DO YOU LIVE AT THE MOMENT?

Own Residence

Flat

Children

Hospital

Care Home

Room / Boarding House

Shelter

REASON FOR APPLICATION:

_______________________________________________________________

_______________________________________________________________

_______________________________________________________________

AAPPPPLLIICCAATTIIOONN FFOORR SSEERRVVIICCEESS IINN AA BBAADDIISSAA FFAACCIILLIITTYY FFOORR EELLDDEERRLLYY

PPEERRSSOONNSS

2

6. TELEPHONE NO: ______ (Code :_____________________) [Self]

CELL: __________________________

ALTERNATIVE CONTACT NAME AND RELATIONSHIP TO APPLICANT:

______________________________________________________________

TELEPHONE NO: ______ (Code :_____________________)

CELL: __________________________

7. GENDER: Male Female

8. RACE: Coloured Indian Black White

9. MARITAL STATUS: ______________________________

10. NAME OF SPOUSE / PARTNER: _____________________________________

OR DATE DECEASED / DIVORCED / SEPERATED: __________

11. HOME LANGUAGE: _________________

12. RELIGIOUS DENOMINATION: _____________________________________

13. PREVIOUS OCCUPATION: _________________________________________

14. PERSON / INSTITUTION RESPONSIBLE FOR YOUR FUNERAL COSTS

Name: _________________________________________________________

Address: _______________________________________________________________

_______________________________________________________________

_______________________________________________________________

Tel no: _______________________

15. DO YOU HAVE A WILL? YES NO

IF YES, WHERE IS IT KEPT? _______________________________________________________________

_______________________________________________________________

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WHO IS YOUR EXECUTOR? _______________________________________________________________

Address:

_______________________________________________________________

_______________________________________________________________

_______________________________________________________________

Tel. no: ______________________________

16. NAME OF HOSPITAL AND FILE NUMBER (Government Patients):

_______________________________________________________________

OR

17. NAME OF MEDICAL AID (Private Patients):

_______________________________________________________________

PLAN NAME: __________________________________________________

Medical Aid Number: _____________________________________________

18. CONTACT DETAILS OF ALL CHILDREN (OR RELATIVES / FRIENDS IF NO

CHILDREN)

Name Address and Tel no Relationship Occupation

[1] Address:

Tel no:

Fax no:

Cell:

E-mail:

[2] Address:

Tel no:

Fax no:

Cell:

E-mail:

[3] Address:

Tel no:

Fax no:

Cell:

E-mail:

4

[4] Address:

Tel no:

Fax no:

Cell:

E-mail

[Please attach a separate list if the space is not sufficient]

19. PLEASE DESCRIBE YOUR HEALTH IN YOUR OWN WORDS?

_______________________________________________________________

_______________________________________________________________

Please list any official medical diagnoses (i.e. diabetes; blood pressure etc.):

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

Allergies: ________________________________________________________________

________________________________________________________________

________________________________________________________________

Do you require any assistance with any of the following? (Specify)

Mobility (walking etc.):

_________________________________________

Bathing/dressing/eating:

_______________________________________

20. FINANCIAL MANAGEMENT

I manage my own finances

I require assistance

It is managed on my behalf

In the event that your finances are being managed on your behalf, please supply full contact

details – name of person responsible, their contact number and relationship.

________________________________________________________________

________________________________________________________________

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21. WHEN WOULD YOU LIKE TO BE ADMITTED?

As soon as possible

Later Approximate Date: _____________________

22. THE UNDERSIGNED HEREBY DECLARES THAT:

- All details in this application form are true and correct.

- Should admission to the Home take place, the undersigned undertakes to abide by the rules

and regulations of Loeriehof Home for the Elderly, even if they are changed from time to

time.

______________________ _______________________

SIGNATURE OF APPLICANT DATE

(OR PERSON RESPONSIBLE)

23. Herewith the below mentioned person responsible / authorised representative accepts

responsibility with regards to the applicant.

Person 1 Person 2

Relationship:

Initials and Surname:

ID no:

Address:

Telephone no:

Cell:

E-mail:

Signature:

Date:

This application is valid for 12 months from date of completion. Thereafter re-application might be required.

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STATEMENT OF INCOME AND EXPENDITURE (Documentary proof of income/expenditure must be attached)

Name of applicant: _________________________________________________ A. INCOME

1. Pension received (Type of pension) Pay point, e.g. bank/post office

Ref. no Monthly income

Self Spouse

1.1

1.2

1.3

2. Annuity (Name of fund)

2.1

2.2

3. Income from trust and maintenance allowances (Name of fund/person)

3.1

3.2

3.3

4. Shares (Name of fund)

4.1

4.2

4.3

5. Director’s fees (Name of company)

5.1

5.2

5.3

6. Cash investments (Specify financial institution) Amount invested

Monthly income

Self Spouse

6.1

6.2

6.3

6.4

7. Fixed property, e.g. farms, dwellings (Full description and where situated)

Municipal assessment

Bond in arrears

Monthly income

Self Spouse

7.1

7.2

8. Other sources if income, e.g. income from business usufruct/Fidei Commissum (Please specify)

Self Spouse

8.1

8.2

8.3

TOTAL R

2

B. TOTAL VALUE OF ASSETS SOLD AND DONATIONS MADE OVER THE LAST 10 YEARS (Please specify) 1. Did you sell or donate any assets (fixed property) during the past ten (10) years? If so, please

give the following details:

[a] Assets sold (description)

[i] Date sold

[ii] Bruto amount received R

[iii] Minus selling costs (please specify on separate page) R

Nett income R

[b] Assets donated (description)

[i] Date donated

[ii] Amount donated R

[c] Cash donated (description)

[i] Date donated

[ii] Amount donated R

2. EXPENDITURE OF A CONTINUOUS NATURE (Documentary proof of expenditure must be

furnished) Specify e.g. medical fund, subscription fees, municipal tax, installments, etc in the case of property:

2.1 R

2.2 R

2.3 R

TOTAL R

I hereby declare that the information furnished by me, is to the best of my knowledge, true and correct and

that the declared income the total income of the applicant is for the _______________tax year.

SIGNATURE OF APPLICANT/AUTHORISED PERSON

DATE

NB: All interest revenue must be certified per certificate of balance by financial institutions.

A false declaration is a punishable offence.

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DECLARATION I certify that, before administering the oath/affirmation, I asked the deponent the following questions and wrote down his/her answers in his/her presence: [a] Do you know and understand the contents of the declaration? Answer: _______________ [b] Do you have any objection in taking the prescribed oath? Answer: _______________ [c] Do you consider the prescribed oath to be binding on your conscience? Answer: _______________ I certify that the deponent has acknowledged that he/she knows and understands the contents of this declaration which has sworn to/affirmed before me and the deponent’s signature/thumb print/mark was placed thereon in my presence.

COMMISSIONER OF OATHS PLACE

DATE

FOR OFFICIAL USE

Nett income R

Boarding per month R

Officer employed by the Department of Social Development

Date

FOR OFFICIAL USE BY A SCREENING OFFICER OF THE DEPARTMENT OF SOCIAL DEVELOPMENT

Gross income R

Minus approved expenditure (specify)

[a] R

[b] R

[c] R

[d] R

Nett income R

Income group code

1

1. FULL NAME AND SURNAME: _____________________________________ 2. AGE: __________________ 3. OVERVIEW OF APPLICANT’S MEDICAL HISTORY EN PREVIOUS

TREATMENT: _____________________________________________________________

_____________________________________________________________

_____________________________________________________________

_____________________________________________________________

4. OVERVIEW OF APPLICANT’S SURGICAL HISTORY:

_____________________________________________________________

_____________________________________________________________

_____________________________________________________________

5. GENERAL EXAM: 5.1 General physical condition

____________________________________________________________

_____________________________________________________________

5.2 Respiratory System

_____________________________________________________________

_____________________________________________________________ 5.3 Cardiovascular System Blood Pressure:_____/____

_____________________________________________________________

_____________________________________________________________

5.4 Urinary System and Genitals (Urine test please)

_____________________________________________________________

_____________________________________________________________

MEDICAL PRACTIONER REPORT FOR ADMISSION TO HOME FOR THE ELDERLY

2

5.5 Digestive and other Abdominal Systems

_____________________________________________________________

_____________________________________________________________

5.6 Endocrine System

_____________________________________________________________

_____________________________________________________________ 5.7 Musculoskeletal System (Name any anomalies)

_____________________________________________________________

_____________________________________________________________

5.8 Central Nervous System

_____________________________________________________________

_____________________________________________________________

5.9 Skin Conditions (i.e. bed sores, scabies etc.):

_____________________________________________________________

_____________________________________________________________

5.10 Other Conditions (Does the patient suffer from any of the following?)

Asthma

Chronic Osteoarthritis KOLS

Tabes dorsalis Rheumatism

Myopathies Hypertension

Previous Hemiplegia CCF

Cerebral Atrophy CVA

Parkinson’s Carcinoma

Contagious diseases

5.11 Does the applicant have control over excretory functions?

_____________________________________________________________

_____________________________________________________________

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5.12 Does the applicant have problems with:

Deafness Poor vision

Impaired Speach Balance

5.13 Has there been any cancer diagnoses? (Please describe)

______________________________________________________________

______________________________________________________________

5.14 Allergies

_____________________________________________________________

_____________________________________________________________

6. MENTAL HEALTH (Please mark where applicable)

Remarks:

_____________________________________________________________

_____________________________________________________________

Remarks:

_____________________________________________________________

_____________________________________________________________

6.1 SCHIZOPHRENIA

Schizophrenia, including hallucinations

Schizophrenia, including delusions / paranoide thoughts

6.2 ALZHEIMERS

Early Stage

Intermediate Stage

Advanced Stage

4

Remarks:

_____________________________________________________________

_____________________________________________________________

Remarks:

____________________________________________________________

____________________________________________________________

Remarks:

_____________________________________________________________

_____________________________________________________________

6.3 DEMENTIA

Early Stage

Intermediate Stage

Advanced Stage

6.4 ANXIETY DISORDERS

Psychosomatic

Obssessive-compulsive

Hysteria

Phobias

6.5 DEPRESSION

Reactive / moderate

Endogenous / severe

Manic-depressive psychosis

6.6 DISORDERS

Delirium / Confusion conditions

Chronic Dementia

Severity:

5

Remarks:

_____________________________________________________________

_____________________________________________________________

Remarks:

______________________________________________________________

______________________________________________________________

Remarks:

_______________________________________________________________

_______________________________________________________________

Remarks:

______________________________________________________________

______________________________________________________________

6.7 PERSONALITY DISORDERS

Passive dependent

Passive aggressive

Bipoler

6.8

SUBSTANCE DEPENDENCY

(Specify – alcohol, medication etc.))

....................................................................................................

....................................................................................................

..........................................

Social

Chronic

Brain Damage

6.9 EPILEPSY YES NO

6.10 MENTALLY DISABLED YES NO

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7. CURRENT PSYCHICAL / PHYSICAL FUNCTIONING

7.1 Orientation with relation to name, time, place etc.:

______________________________________________________________

7.2 Ability to communicate:

______________________________________________________________

7.3 Assistance where required (mark where applicable):

7.3.1 MOBILITY

Moves independently

Moves with aides – walking stick etc.

Wheelchair bound

Immobile – bed bound

7.3.2 CLOTHING

Does not require assistance with dressing

Requires supervision with dressing

Requires assistance with buttons etc.

Completely dependent

7.3.3 FEEDING

Does not require any assistance

Requires supervision

Requires some assistance with spreading bread, cutting meat etc.

Completely dependent

Dependent on tube feeding

7.3.4 MEDICATION

Takes madication independently without assistance

Uses medication independently, but requires assistance with ordering medication and monthly check on medication

Medication has to be administered – specialised assistance required.

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8. CURRENT MEDICATION (Specify with relation to physical and mental health:)

_____________________________________________________________

_____________________________________________________________

_____________________________________________________________

9. HOW LONG HAVE YOU BEEN TREATING THE PATIENT/APPLICANT?

____________________________________________________________

10. GENERAL REMARKS:

_____________________________________________________________

_____________________________________________________________

_____________________________________________________________

_____________ _________________ _____________________

PRACTITIONER PRACTITIONER DATE [PRINT] [SIGNATURE]

Address: ___________________________________________________________

Tel nr: _________________________

7.3.5 PERSONAL HYGIENE

Does not require assistance

Requires encouragement and supervision

Requires some assistance

Completely dependent

1

Contact the Department Social Development on 044 382 0056, Demar Building, Main Road, Knysna, 6571

1. SURNAME (Applicant): ____________________________________________

FULL NAME (Applicant): __________________________________________

ID NO:

DATE OF BIRTH :

ADDRESS: ________________________________________________________________

________________________________________________________________

________________________________________________________________

TELEPHONE NO: (Code:_________) __________________

CELL: ___________________________

2. FAMILY COMPOSITION AND BACKGROUND:

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

3. BEHAVIOURAL CHARACTERISTICS (Personality, interests, adapting in a group etc.):

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

4. SOCIAL CIRCUMSTANCES:

Care:

Cares for self

Cared for by children/family/friends/other

SSOOCCIIAALL WWOORRKKEERR RREEPPOORRTT

2

Quality of Care:

Good

Average

Poor

Social interaction:

Sufficient interaction with family/friends

Interaction is limted

Lonely

Social adaptability:

Well adapted

Difficulty adapting

Depressed

Behavioural issues

Motivate: ________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

5. ENVIRONMENT AND HOUSING CIRCUMSTANCES (Living arrangements /

motivation for admission / housing problems):

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

5.1 CURRENT HOUSING:

Own house

Rental house

Boarding house

Home for the Elderly

Hospital

Resides with ohers

Resides with children

Flat

Shelter

Retirement Village

3

5.2 Surety of current accommodation:

Unable to determine

Uncertain

Has to move

Can remain, but circumstances does not suit the elderly

Motivate: ________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

6. PHYSICAL AND MENTAL FACTORS

Is the applicant able to: YES NO To a degree

(Mark with a √)

6.1 PHYSICAL

* Prepare and cook own meals

* Keep living areas tidy

* Bath self

* Dress self

* Eat without assistance

* Move freely and without assistance

Health: (Mark with a √) Good Uncertain Poor

6.2 MENTAL (Poor memory, comprehension, depression, psychosis, aggressive behaviour):

______________________________________________________________

______________________________________________________________

______________________________________________________________

Please mark (√)

Coherent thoughts Forgetful

Displays a lack of interest Clear signs of Dementia

Psychiatric report attached? Yes No

6.3 Is there a history of substance abuse and/or dependancy? If so explain:

________________________________________________________________

________________________________________________________________

________________________________________________________________

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7. ECONOMIC CIRCUMSTANCES (Brief overview of income and expenditure):

________________________________________________________________

________________________________________________________________

8. REASONS FOR ADMISSION (Age, social circumstances, housing problems, physical and

mental frailty, economic circumstances, loneliness):

________________________________________________________________

________________________________________________________________

________________________________________________________________

9. SERVICES ALREADY DELIVERED (Including applications to other homes):

________________________________________________________________

________________________________________________________________

10. RECOMMENDATION (Specify placement i.e. room, frail care, flat):

________________________________________________________________

________________________________________________________________

________________________________________________________________

11. How long have you known the applicant? ____________________________

_______________________ _______________________ _______________

SOCIAL WORKER NAME OF ORGANISATION DATE

________________________________

Registration no: Social Worker